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  • When Chronic Hoarseness Isn't Reflux Disease

    When Chronic Hoarseness Isn't Reflux Disease

    David A. Johnson, MDApril 15, 2015
    Refractory Laryngeal Symptoms

    Hello. I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another GI Common Concerns—Computer Consult.

    Today I want to talk about the very challenging problem of patients with refractory laryngeal symptoms.

    These patients come in and complain about hoarseness, voice changes, or a sensation here [in the throat], and they invariably are referred to an ear, nose, and throat (ENT) specialist. The ENT specialist performs a laryngoscopy and says, "Aha, it's a red larynx. You need to go see the gastroenterologist because, of course, this is gastroesophageal-reflux related."

    Is It Reflux?

    The gastroenterologist then sees the patient and perhaps prescribes a medication; we may prescribe a proton pump inhibitor (PPI). We may order a pH study or endoscopy, which are rarely helpful. I typically have pH studies performed during therapy to see whether the patient has ongoing reflux (acidic or nonacidic) and try to correlate it with the patient's symptoms. The gastroenterologist says, "No, you don't have reflux."

    If the patient didn't improve with a PPI, what happens to these people?
    Understanding Habituation

    I want you to understand a key concept, and hopefully this will serve you well. It's called habituation. I learned this in dealing with these patients for a long time.

    These patients come in, and I'll be listening to them as they talk, and their symptoms are frequently a gravelly voice, voice change, or sensation in the throat. The patient will say, "Well, doc, [clears throat] um, [clears throat] um, [clears throat]."

    What you pick up right away is that there is some perpetuation of a behavior here known as habituation. What we are learning is that these patients may get into a cycle that they just can't get out of.

    These patients may truly have had gastroesophageal or laryngopharyngeal reflux. As the reflux improves, the patients, however, have learned to deal with it in the way that they clear their throats or inflect their voices, and that can actually incite an ongoing inflammatory response.

    The Habituation Evaluation

    So I take a good voice history. I listen to these patients when they start talking about hoarseness or laryngeal symptoms.

    As we are discussing this in the clinic, I listen in particular for habituation-type behavior. I also listen to their stories and ask questions. Are you a singer? Do you talk on the phone a lot? Do you talk in public? Are you a mom or dad who goes to sports games and yells and screams? Have you had voice fatigability over the course of a day? Do you find that your voice gets a little bit tired and strained? A lot of these answers come back as "yes."

    You find an avenue to say not just "you don't have reflux disease," but you may be able to develop a way to break this habituation.
    Is It Repetitive Habituation-Type Behavior?

    To help them understand, I use the analogy of clapping your hands together. If you clap your hands together, they get red and swollen. That is analogous to what the vocal cords are doing. I tell patients that as they clear their throats or have a dry cough or try to cough because of a sensation in their throats, it has the same effect. It perpetuates the inflammatory response.

    Habituation and Inflammatory Response

    First of all, you want to make sure that if the patient has reflux symptoms, the reflux is controlled, so it is reasonable to have a trial of a PPI. If the patient has a postnasal drip, you take care of the postnasal drip. If the patient has other modifiable environmental exposures that may make it difficult to control the patient's postnasal drip or any allergies, you address those factors.

    In between are the patients who don't seem to get any better, and that's why I want you to learn this habituation evaluation.

    I ask these patients a couple of questions. I ask about their voice and their patterns of speech. Do they find that people tell them they don't sound the same as they used to?

    When patients start to have voice fatigability, they will change their pace of speech. They may speak more loudly to overcome what is perceived as a voice weakness. They may change the pitch of their speech. All of these efforts take them out of what I call the quiet, restful voice and induce an inflammatory response, so they perpetuate this behavior. They perpetuate the habituation with repetitive throat clearing and coughing, and it just never goes away.
    Breaking the Cycle

    After I get a good perspective that this sounds like repetitive habituation-type behavior, I talk with the patients about that and then look at a variety of things that they can do to help themselves.

    One thing I insist on is having them carry a bottle of water, and every time they feel that sensation of thick secretions or a swelling-type feeling in the back of their throats, they take water rather than trying to clear it with phonation. If they have to clear it, I ask them to clear it without phonating. They should try to clear their throats softly, rather than harshly, and try to minimize the number of attempts to clear it.

    Make sure that patients understand that this is going to be a process, and it's an education. They need to recognize that they need to throttle back on using their voices if they find that their voices start to become hoarse or tired. They need to cut back on their telephone calls, yelling and screaming at games or parties, or whatever they do to overuse their voices. In social situations, they need to use their quiet voices, rather than projecting their voices, to get the inflammatory response under control.

    If the patient can't carry a bottle of water, I recommend carrying lemon drops, which help the parotid salivary secretions to flow more easily. When they are out and about, these are things they can carry with them. Emphasize hydration, and tell patients to minimize substances that dehydrate them such as caffeine and alcohol. If these patients are smokers, try to get them to stop smoking.

    Breaking the Habituation Cycle

    Make sure that the laryngologist has looked at their vocal cords, or do so if you perform an endoscopy. Make sure that all aspects of the problem have been taken care of.

    If cough is the primary complaint and the patient is a nonsmoker with no evidence of postnasal drip or allergies, has a clear chest x-ray, and is not taking an angiotensin-converting enzyme inhibitor, you should be able to solve many of these issues just by addressing the habituation response and understanding why the patient is really coughing.

    Habituation is very important, and you need to understand how to ask the right questions because these patients are very frustrated. They don't improve. They see their ENT specialists and their gastroenterologists, and they don't come back any better. They are stuck in a continual response cycle, even though whatever started that response may now be under control. Habituation perpetuates the problem.

    Voice Retraining

    I have also found it very helpful to engage with a voice specialist—a physical therapist who is uniquely trained in voice. This is not just a standard speech rehabilitation specialist. It has to be somebody who understands the complexity of voice retraining. They use phonation and exercises to help with pitch and expressions, and they get the patient back down to a more restful voice.

    Referral to a Voice Specialist

    If you have one of those specialists, you should refer to that person. This is not a standard referral. There are very different perspectives among physical therapists and speech therapists with respect to voice retraining.

    It's important, with patients who aren't improving, to think about habituation, take a good voice history, and do something to help these people because they are in a never-ending cycle.

    Hopefully, this gives you some insight with your next patient who presents with similar complaints.

    I'm Dr David Johnson. Thanks again for listening.


    Medscape Gastroenterology © 2015 WebMD, LLC

    Cite this article: When Chronic Hoarseness Isn't Reflux Disease. Medscape. Apr 15, 2015.

  • #2
    my personal thoughts on this article

    I just read this article, "When Chronic Hoarseness Isn't Reflux Disease". What I'm about to say is not meant as a criticism but a my honest thoughts on it.

    There could be something called "Hibituation" but in my humble opinion that is not what is going on in the LPR mystery. From my experience and last 3 1/2 years of research on the subject of LPR it is not "Habituation" as described in this article. In my opinion, as a patient who had a very severe case of LPR for 2+ years, I can tell you there is a lot of speculation about what causes LPR. Most of it from my view is incorrect.

    The following is my two bits based on what turned around my spiraling downward case of LPR. My doctors after numerous medications and surgery over 2 1/2 years, in which I got worse and worse, told me in the end, that there was nothing more they could do for me. They even went so far as to tell me that it was caused by stress. I knew they were 100% wrong. I had no stress. But I am not a doctor or a scientist to quibble with them and for some reason when nothing worked my doctors gave up on me and left me alone to deal with the problem. I knew I'd either bleed out from the burn ulcers or develop cancer. I was between a rock and a hard place and knew my time was limited in which to figure out what was wrong with me.

    After studying night and day for 3 1/2 years I believe the root cause is low D levels and low UVB light due to the latitude one lives in, or being born with low D levels, or being inside day after day or wearing clothes when outside in the sunshine, being heavy, aging, or dark skin.

    There are varying degrees of LPR. Some are mild. When LPR is mild it is often times misdiagnosed as asthma or allergies for years...even for decades. Patients blow nose steroids up their nose for years or take asthmas medicines for years. A crying shame as the patient is misdiagnosed and should be told to get into the sunshine at the high sun hour, get as many clothes off as possible and get their D levels to 70. Part of my treatment also is to get myself below the 31st latitude on vacation in the winter months as often as I can afford it.

    Through the shear will to live and not die early I delved into the science and tried to piece together the mechanism for acid vapor rising and burning my throat. When I finally understood the esophagus and the sphincters and how it all worked together then I had to understand to what was causing my intractable pain and burn ulcers of the throat. I'm lucky to still be here.

    If you want to have a sense of what severe LPR is like, think of a piece of meat searing on the barbeque...only in a severe case of LPR it never stops searing! In a mild case of LPR it presents as allergies or asthma. There is a small bit of acid vapor rising to the thin one layer of skin of the throat, sinuses, ears, and lungs via breathing, where it does not belong. And it is burning throat tissues! Patients can actually act like their "crazy" with LPR but anyone would act that way when one is basically burning to death on the very sensitive tissues of the throat. The throat tissue is only one layer thick so the acid vapor burns through rather quickly and then starts burning on the nerves that go up into the head and down into the body. For 2 1/2 years I literally had to pace to walk off pain. And I felt no one really understood the nightmare of severe LPR. Instead of understanding and caring my doctors just stood silent and never thought outside of the box. I will never forget their indifference.

    What I'm sharing is based on my research and recovery over the last 2-3 years. Recovery takes time. Recovery with D therapy both with D3 and sunshine combined, will take time but the patient will get better. It's not a cure because low D levels for too long causes permanent damage. I have about a 100% recovery and in the winter LPR returns about 5%. I was not even be able to drink water as LPR progressed. I had a severe case of LPR. Currently I only avoid tomatoes, onions and raw garlic, cumin, garlic, nitrates and I have my medications checked to make sure they don't exasperate GERD/LPR. But I try to stay away from meds. I can only take acetaminophen for an occasional headache. Aspirin will send a small acid vapor up my throat. It shows that my UES sphincter still has a permanent bit of atrophy or loss of muscle twitch. Sunshine and D3 strengthens muscles and there in lies the root problem of LPR. Low D levels, low sunshine from modern living causes permanent damage to muscle tone. Low D levels cause a very long lists of other illnesses. Too many to mention here.

    All my doctors got it wrong and I had oodles of specialists. I had a total of 3 primaries. 3 ENTs. 3 GIs. 2 endocrinologists. 3 surgeons. And not one of them thought about testing me on D or trying to get my D levels up over 50. I'd like to know why a endocrinologist doesn't even think of low D?! If they had, they would have saved this patient indescribable pain and despair. And saved the medical system loads of money on worthless medications and surgery. What a waste of money for something so simple and inexpensive to fix. Why D testing from utero through death is not part of preventative medicine is a testament to the crime of silence on this subject.

    I'm sure the Dr. that wrote this article cares about LPR patients. But like my Drs. the article misses the root cause: making sure evolutionary D scores were up closer to a 70 D score. I hope someday D testing and D scores will be brought into preventative medicine and save so many people from a long long list of illnesses we all suffer from...my LPR was how my low D levels presented in me. In populations around the world its a long list of illness too long to list here. Thank you for reading my thoughts on this.

    Comment


    • #3
      While I think the habituation may not be a root cause, I think it is a situation that can definitely exacerbate the already sore area and prevent one from healing.

      I too had LPR and it was severe at times. It was getting worse and worse and I was on double Nexium. I was desperate to get rid of the incessant burning. It was driving me crazy. Then one day a book was introduced on this forum about excessive carbs and how a high protein diet would help GERD. I wasn't convinced but I tried it. My burning was gone in 2 days! I actually don't think the LPR was resolved by the high protein but while trying to conform to this diet, I stopped drinking milk and started drinking soy milk. I haven't gone back to milk and the few times I did the LPR flared up.

      In your case you found low levels of Vit. D to be the culprit. I found milk was mine....at least in the burning laryngo area. I still have a malfunctioning lower esophageal sphincter and still take meds to protect my esophagus but the LPR symptoms are gone.

      What I have learned on this forum, and I've been here many years, is that people eventually get their GERD/LPR resolved and the majority do it by finding out on their own what works for them. Sometimes the doctors are clueless and sometimes they can lead you to a proper path. I believe there many variables to solving this GERD/LPR problem and each person has to find what works for them.

      Comment


      • #4
        hi elena.. need ur help..

        Hi elena,
        I am 27 year age..
        I read all of ur post from first to last.. I think i am too suffering the same condition like you..
        I had acidity problems from my childhood..
        But haven't imagined that it might get worse..
        Few months ago i experienced a very bitter taste liquid coming till my throat when i was asleep in night.. Nd my throat started burning like hell.. I vomited immediately because that taste was so bitter that i couldn't bear it..
        Next day i was having trouble swallowing anything,burning in the chest,burning in the throat..
        even i was not able to drink water easily...
        When i visited ent doc he said that my throat was very raw full of mucous and very red nd was burning a lot..
        he said I had acid reflux issues..
        He gave me ppi 20 mg..
        But things started getting worse..
        I was not even able to eat as i had problems swallowing nd my throat was very sore nd red nd the burning of throat was continuous with tons of mucous... that thing had damaged my throat..
        When i visited doc he said take the ppi for a month and dont eat spicy..
        After few days i was able to eat but when i eat anything my throat would start burning again and that burning would not stop for next few hours..
        Now my condition is after reading many peoples post i started taking Nexium 40 mg twice a day from last week..
        Now the burning of the throat is reduced nd can eat nd swallow somewhat easily..
        But the problem now is with my throat as the mucous with continuous sore throat nd hoarseness is still annoying me plus the burning is not stopped at all but reduced a little...
        Please suggest me something so that i can get rid of this burning,hoarseness nd sore throat issues..

        Comment


        • #5
          Hi elena and welcome to the heartburn-help discussion board.
          My suggestion to you is to just read, research and try all the things that supposedly help others. Raising the head of your bed, not eating before lying down, etc. You may find that a certain food needs to be eliminated or that you will need to change your diet and lifestyle habits. What have you done to help yourself besides medications and keeping away from spicy foods? Have you been to a GI doctor and had an endoscopy? Have you tried a high protein, low carb diet? Are you considering surgery? This may sound strange but does any analgesics like Tylenol help relieve the pain? It's not a cure but when the throat is burning you will try most anything to stop it at lease for a few hours. Let us know if anything helps you.

          Comment


          • #6
            Anurag: I am so sorry for your suffering with LPR. I can not tell you what to do. I believe our moderator gives good advice to start with a Gastroenterologist doctor and get the appropriate tests and advice. What I can do is tell you what I did for myself. I studied and researched and drilled down into the all the pieces of LPR world wide. My doctors did not have an effective way of treating LPR. I got sicker and sicker under their treatments and surgery. I think I diagnosed myself correctly because I got well...

            I can tell you that my doctors put me on every PPI known to the medical system. None worked for me. In fact I grew sicker and sicker from LPR and the side effects of the medications. The meds gave me weak legs and in the end pneumonia...severe pneumonia. None of my doctors told me to stop the PPIs. I had to go into the web and read what the effects of the PPIs were. And I had all the severe symptoms from PPIs. I stopped the PPIs and though I had reflux rebound, I felt it was better to get rid of severe pneumonia that antibiotics couldn't get rid of. The pneumonia dissipated within 24 hours of stopping PPIs.

            I continued to burn to death but at least I didn't have pneumonia and burning to death together.

            Then the next problem was making my way to the Nissan fundoplication surgery my GI said was the only answer to my excruciatingly painful LPR problem. The surgeon's opinion was that LPR would not go away with the Nissan Fundoplication. I didn't care. I demanded to have the surgery as I felt trying something was better than burning to death. The surgeon's thoracic surgeon supported me also agreed that I might have a chance of stopping the acid vapor up the throat with the Nissan Fundo. So the surgery went forward.

            The outcome of the surgery was not good. However in it's defense I will say that the tests showed I went from a PH study score of 40 to 0.4. While not a perfect tight lower sphincter was achieved, I at least had a lower sphincter that was "almost" good as new. This is were the mystery of LPR tortured me 24/7. Imagine burning to death worse each day pondering why the Nissan fundo didn't at least get me 90 % better. I was tortured by the "whys" because my pain was so severe I began to lose weight because it hurt so much to drink water and swallow what little food I was able to get down.

            Why why why I asked myself, if the Nissan was almost perfect did I get 10x worse with LPR after surgery? That was the enormous question before me as a patient. My doctors looked at me blank. As the months rolled into a year after surgery they sent me to behavioral counseling as they thought the LPR was stress related. I knew it was not related at all. But I did it because it was all I had was to follow what they wanted to try. It was hopeless.

            When I retired and moved, it compounded the problem because I could only email my surgeons and doctors. It was a living nightmare. How I kept going was shear desire to live...I was a burn patient on the inside and no one could see it except the ENT. He confirmed I was so severely burned with burn ulcers that he insisted not only on a biopsy of the throat for cancer but that on a separate issue my thyroid had large growth on it that was probably cancer. It was all I could do to get to surgery because I was so severely burnt with ulcers all over my throat. The acid was literally eating a hole into the nerves that run up into the head and down into the body. I literally shook down my arms and legs from the acid vapor. I slept fitfully 5 minutes at a time. I would go to sleep hoping I wouldn't wake up as the pain was so unbearable. Unless one has experienced this type of searing nerve burn one can not imagine how horrific it is. It is a horrible death...of which I was certain I was going to arrive at. My sister, a nurse practitioner, also felt I was slowly deteriorating and advised me to get my final papers in order. It was a very hard place to be.

            I had the biopsy and thyroid removal and I was very lucky and had no signs of cancer...yet. I knew I had limited time to figure this out.

            I kept studying and studying...desperate to find the thread that could break the mystery of my LPR. One day, while quietly weeping instead of using the word sphincter I used the word "muscle" and typed into the world wide web a search, "what strengthens muscles". It had slowly dawned on me that the surgeon had "strengthened" with surgery my lower esophageal sphincter but there was no surgery to strengthen the upper sphincter. At least that was my thinking. I had come to very slowly realize that I had a muscle atrophy problem. From all my humble research I felt I had narrowed down that the muscle atrophy was causing a bit of natural acid vapor that everyone has that rises from the stomach get past my UES.

            During the last 5 months before my discovery I also developed 2 other health issues: a leaking bladder that got worse each day and severely locked up shoulder blades. I literally was so ashamed of being sick and falling apart. My doctors gave me the cold shoulder and implied it was "stress".

            I came to the realization that the UES (upper esophageal sphincter) was not stopping the acid vapor from hitting my throat. I figured out I had a type of muscle atrophy. But remember this took time for me to absorb this information and draw a nexus to my condition. When I pulled up that web inquiry "what strengthens muscles" a long list of articles came up...but one that caught my eye was one that read something like this, "athletes use vitamin D to strengthen muscles during exercise". That is the moment I knew I had found my answer. When I opened up the article it said that D is not a vitamin but a pre-hormone and that it is made by the sun on the skin...I went into full drive and studied everything on D. It is a powerful pre-hormone. I got better from LPR steadily over the next two years, and the leaking bladder and locked up shoulder joints disappeared with in 24 hours! Never to return.

            This is what I did for myself: I got a D and B12 test immediately and I track my D and B12 levels to this day. I researched and because I lacked a science and medical background I had to read and digest many opinions and sift through many layers of thinking. I also take magnesium, boron and selenium. I came to the conclusion that my best bet was looking at what was lacking in my evolutionary history. It was direct sunshine on the skin. I worked inside in an office all my adult life. And I avoided the sun for forty years. I grew up in a very foggy area of the planet at the 37th latitude. This causes a long long list of all type of illnesses. It causes permanent damage to every process of the human body. The sun is so important to health. We have lost our evolutionary practices. We don't roam the forests anymore or eat the foods of the forest.

            I keep my D level at a US score of 80 and my B12 between 800-1,000 for B12. It has been miraculous for me. I now carefully get full direct sun on my skin at high sun hour in the nude (I have a private patio and I'm careful not to burn!) and take D3 based on weight: 35 IU of D3 for every 25 lbs. LPR slowly and steadily disappeared over the next 2 years. That is my story. I continue 4 years later to study sunshine and the science of D and am convinced that 70 % of all illnesses are caused by low D levels and lack of direct sun on the skin. I can only hope that the scientists of the world working on this can get this out as quickly as possible and save so many people from suffering and losing their lives for something so simple and effective...and just think of the monies it would save nations around the world. I hope my suffering and recovery can be the beginning of a new way of looking at causes of illness.

            Comment


            • #7
              hi elena

              hi elena.. thanx for ur reply.. I am now on 10th day of nexium nd I am feeling bit better now.. although I am avoiding spicy food but I can swallow better now..
              but now the only issue is with my throat..
              after taking nexium soreness has been decreased by 30% but still my throat is sore nd its red I can visibly see it with flash in mirror.. can u please tell me how can I get rid of that..
              nd i read ur throat was also red and sore.. how is it now nd what should I do to get rid of this throat issues..
              thanks

              Comment


              • #8
                hi moderator..

                nexium is been helping me of heartburn,throatburn.. I am feeling good now in 10 days of taking nexium but now the only issue is that acid has damaged my throat as it is really red looking nd have sore throat issues.. how can I heal my throat as its redness is still there I can see it visibly in mirror.. what should I do.. any suggestions..??

                Comment


                • #9
                  Originally posted by Elena View Post
                  Anurag: I am so sorry for your suffering with LPR. I can not tell you what to do. I believe our moderator gives good advice to start with a Gastroenterologist doctor and get the appropriate tests and advice. What I can do is tell you what I did for myself. I studied and researched and drilled down into the all the pieces of LPR world wide. My doctors did not have an effective way of treating LPR. I got sicker and sicker under their treatments and surgery. I think I diagnosed myself correctly because I got well...

                  I can tell you that my doctors put me on every PPI known to the medical system. None worked for me. In fact I grew sicker and sicker from LPR and the side effects of the medications. The meds gave me weak legs and in the end pneumonia...severe pneumonia. None of my doctors told me to stop the PPIs. I had to go into the web and read what the effects of the PPIs were. And I had all the severe symptoms from PPIs. I stopped the PPIs and though I had reflux rebound, I felt it was better to get rid of severe pneumonia that antibiotics couldn't get rid of. The pneumonia dissipated within 24 hours of stopping PPIs.

                  I continued to burn to death but at least I didn't have pneumonia and burning to death together.

                  Then the next problem was making my way to the Nissan fundoplication surgery my GI said was the only answer to my excruciatingly painful LPR problem. The surgeon's opinion was that LPR would not go away with the Nissan Fundoplication. I didn't care. I demanded to have the surgery as I felt trying something was better than burning to death. The surgeon's thoracic surgeon supported me also agreed that I might have a chance of stopping the acid vapor up the throat with the Nissan Fundo. So the surgery went forward.

                  The outcome of the surgery was not good. However in it's defense I will say that the tests showed I went from a PH study score of 40 to 0.4. While not a perfect tight lower sphincter was achieved, I at least had a lower sphincter that was "almost" good as new. This is were the mystery of LPR tortured me 24/7. Imagine burning to death worse each day pondering why the Nissan fundo didn't at least get me 90 % better. I was tortured by the "whys" because my pain was so severe I began to lose weight because it hurt so much to drink water and swallow what little food I was able to get down.

                  Why why why I asked myself, if the Nissan was almost perfect did I get 10x worse with LPR after surgery? That was the enormous question before me as a patient. My doctors looked at me blank. As the months rolled into a year after surgery they sent me to behavioral counseling as they thought the LPR was stress related. I knew it was not related at all. But I did it because it was all I had was to follow what they wanted to try. It was hopeless.

                  When I retired and moved, it compounded the problem because I could only email my surgeons and doctors. It was a living nightmare. How I kept going was shear desire to live...I was a burn patient on the inside and no one could see it except the ENT. He confirmed I was so severely burned with burn ulcers that he insisted not only on a biopsy of the throat for cancer but that on a separate issue my thyroid had large growth on it that was probably cancer. It was all I could do to get to surgery because I was so severely burnt with ulcers all over my throat. The acid was literally eating a hole into the nerves that run up into the head and down into the body. I literally shook down my arms and legs from the acid vapor. I slept fitfully 5 minutes at a time. I would go to sleep hoping I wouldn't wake up as the pain was so unbearable. Unless one has experienced this type of searing nerve burn one can not imagine how horrific it is. It is a horrible death...of which I was certain I was going to arrive at. My sister, a nurse practitioner, also felt I was slowly deteriorating and advised me to get my final papers in order. It was a very hard place to be.

                  I had the biopsy and thyroid removal and I was very lucky and had no signs of cancer...yet. I knew I had limited time to figure this out.

                  I kept studying and studying...desperate to find the thread that could break the mystery of my LPR. One day, while quietly weeping instead of using the word sphincter I used the word "muscle" and typed into the world wide web a search, "what strengthens muscles". It had slowly dawned on me that the surgeon had "strengthened" with surgery my lower esophageal sphincter but there was no surgery to strengthen the upper sphincter. At least that was my thinking. I had come to very slowly realize that I had a muscle atrophy problem. From all my humble research I felt I had narrowed down that the muscle atrophy was causing a bit of natural acid vapor that everyone has that rises from the stomach get past my UES.

                  During the last 5 months before my discovery I also developed 2 other health issues: a leaking bladder that got worse each day and severely locked up shoulder blades. I literally was so ashamed of being sick and falling apart. My doctors gave me the cold shoulder and implied it was "stress".

                  I came to the realization that the UES (upper esophageal sphincter) was not stopping the acid vapor from hitting my throat. I figured out I had a type of muscle atrophy. But remember this took time for me to absorb this information and draw a nexus to my condition. When I pulled up that web inquiry "what strengthens muscles" a long list of articles came up...but one that caught my eye was one that read something like this, "athletes use vitamin D to strengthen muscles during exercise". That is the moment I knew I had found my answer. When I opened up the article it said that D is not a vitamin but a pre-hormone and that it is made by the sun on the skin...I went into full drive and studied everything on D. It is a powerful pre-hormone. I got better from LPR steadily over the next two years, and the leaking bladder and locked up shoulder joints disappeared with in 24 hours! Never to return.

                  This is what I did for myself: I got a D and B12 test immediately and I track my D and B12 levels to this day. I researched and because I lacked a science and medical background I had to read and digest many opinions and sift through many layers of thinking. I also take magnesium, boron and selenium. I came to the conclusion that my best bet was looking at what was lacking in my evolutionary history. It was direct sunshine on the skin. I worked inside in an office all my adult life. And I avoided the sun for forty years. I grew up in a very foggy area of the planet at the 37th latitude. This causes a long long list of all type of illnesses. It causes permanent damage to every process of the human body. The sun is so important to health. We have lost our evolutionary practices. We don't roam the forests anymore or eat the foods of the forest.

                  I keep my D level at a US score of 80 and my B12 between 800-1,000 for B12. It has been miraculous for me. I now carefully get full direct sun on my skin at high sun hour in the nude (I have a private patio and I'm careful not to burn!) and take D3 based on weight: 35 IU of D3 for every 25 lbs. LPR slowly and steadily disappeared over the next 2 years. That is my story. I continue 4 years later to study sunshine and the science of D and am convinced that 70 % of all illnesses are caused by low D levels and lack of direct sun on the skin. I can only hope that the scientists of the world working on this can get this out as quickly as possible and save so many people from suffering and losing their lives for something so simple and effective...and just think of the monies it would save nations around the world. I hope my suffering and recovery can be the beginning of a new way of looking at causes of illness.
                  Oops, miswrote how I take D3...either formula is good:
                  35 IU of D3 for every pound of weight
                  OR
                  1,000 IU for every 25 pounds
                  both formulas I use. One is slightly more exact and the other is a quick calculation.
                  And I tested often until I learned what dose got me hovering at a D score of 70-80, which I find keeps LPR from returning. From time to time I feel LPR returning, and I get a D test right away, and in each and every instance my D level has dropped to 62. I up my D3 for 3 days to 10,000 IU of D3 and then drop back to my normal intake based on weight. So far so good. I'm lucky I have found a way to control LPR. I have come to the conclusion that my LPR is permanent damage to muscle tone from 60 years of low D levels. I was so lucky to have saved the best years of my life to enjoy with my family for as long as it lasts.
                  Elena

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